Pain at The End Of Life–Still Not Doing Enough

Chronic pain sufferers already know that much needs to be done to address the issues of the 100 million plus Americans who have to endure their pain. For many, the quality of life is substandard.

Let’s add another chapter to the book—pain at the end of life.

A study funded by the National Institute of Nursing Research out this week reports that people experience pain in the last year of life actually increased by nearly 12 percent between 1998 and 2010.

The observational study looked at over 7,200 patients who died who enrolled in the national Health and Retirement study, a survey of Americans over age of 50. After the loved one died, family members were asked questions about their loves ones’ end-of-life experience, including whether the person suffered pain, depression of periodic confusion.

Most physicians tend to under treat pain and other symptoms at the end of life because they don’t recognize them or are hesitant to candidly talk about the process of dying and the pain associated with it, said Dr. Tim Ihrig, a palliative care physician at UnityPoint Health in Fort Dodge, Iowa.

Should this be surprising?

For many public health policy experts, these finding are disappointing. In 1998, the Institute of Medicine released a report called: Approaching Death: Improving Care at the End of Life.

What should be done at the end of life? It argued for more candor and transparency.

Determine diagnosis and prognosis and communicating these to patient and family.

The study was considered a breakthrough then. But the follow-up study out this week indicates that 15 years later, not much has changed–in fact things have become worse.

“A lot of practitioners aren’t honest. We fail to empower patients with the truth,” said Dr. Ihrig. “In that setting, it’s easier to continue to do procedures and diagnostics rather than having that conversation which is very honest and very difficult.”

The number the number of palliative care programs rose and hospice use doubled between 2000 and 2009.

“We’ve put a lot of work into this and it’s not yielding what we thought it should be yielding. So what do we do now?” asked Dr. Joanne Lynn, a study author who directs the Center for Elder Care and Advanced Illness at the Altarum Institute.

Like chronic pain itself (which needs a lot more research), pain at the end of life also is understudied.

The North American Journal of Medical Sciences said the following in 20111:

“The sequential use of analgesics drugs and opioids are considered effective and relatively inexpensive for relieving pain, but no well designed specific studies in the elderly patient are available. There are not specific recommendations about the long-term use of complementary and alternative therapies and although their effectiveness remains unproven they should not be discouraged. Palliative sedation may be a valid palliative care option to relieve suffering in the imminently dying patient.”

Again, we seem to be more interested in developing standards of care than in alleviating pain and suffering.

Doctors are reluctant to treat pain because they have so little training in doing so. Many experienced gerontologists and pain managers have this experience, but how much are they involved with end-of-life care as opposed to oncologists and cardiologists?

We seem to hold a fundamental belief that pain is, in itself, not a life-threatening sign, and therefore the need for adequate treatment is secondary to managing electrolyte levels or blood pressure.

But for the millions in pain, laboratory measurements are less important than feeling comfortable, especially at end of life.

Please, let not physicians forget that the patient in front of them is a human being with subjective feelings that are just as important to their quality of life, if not more so, than their blood pressure.

And please, let’s alert all physicians to the huge problem opioid tolerance presents in the management of chronic pain patients. Tolerance attenuates the analgesic effects of our strongest pain medications by 50% or more. If we are to reduce suffering, we need concentrated work on effective strategies, not only to prevent diversion, but to increase the effective analgesia of our strongest medications in the growing population of opioid tolerant patients, many of whom suffer from end-of-life stage misery. While the conservative change in our current equal analgesic tables may have saved lives in the population of the opioid naive, their bias against the chronic user may be causing getting inadequate pain relief from prescribing medication at these levels.

4 years ago

GeorgiaPeach

No one in their final days should live in pain. If opioids give them relief they should be able to have it. I think they should be able to have marijuna if that’s what they want – it’s not like they need to worry about becoming dependent or addicted to either drug!

4 years ago

Mark Ibsen

I just saw patient today, with pancreatic cancer would been dropped by her family doctor for using too many opiates.
Unbelievable!